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To truly understand how we can better treat those with glaucoma, we must first be clear on what exactly it is and the consequences that accompany it. The strict and academic definition of glaucoma is an optic neuropathy with corresponding changes in visual field that has an association with intraocular pressure (IOP). The most glaring point to that description is a “link” to IOP but not necessarily a requirement. However, you and I live in the real world where people and their quality-of-life is what truly matters. We want to know what can we do about the problem. Despite the scientific description, the management of glaucoma still relies on decreasing IOP as it is the only modifiable risk factor. Consider two extremes in the spectrum of this disease: low-tension glaucoma and angle closure. Both are still treated by utilizing methods that reduce IOP although there are other factors that are being contemplated in their pathophysiology. This is why we perseverate on patients’ IOPs.
The next critical factor to recognize is that glaucoma remains a disease that is treated but not cured. Even in some of the more unique cases such as steroid-induced glaucoma, the removal of the offending medication does not eliminate the patient’s susceptibility to glaucoma or any optic nerve damage that may have already occurred. Therefore, the strategies used in caring for our patients revolve around how to manage it. It would be so much simpler to just give a patient a prescription for a course of antibiotics that resolves the issues such as in a bacterial infection. The situation and challenge is much more different and, in many instances, difficult when it comes to glaucoma. Instead, we need a plan that is lifelong. This implies we develop a treatment that has a long-term focus that is sustainable.
The most effective approach I have found to express these distinct considerations of glaucoma to my patients is using a sports analogy. Unlike cataract and its surgical intervention which is like a sprint, the thought process and execution of care in glaucoma is like a marathon. In other ways, we are in it for the long haul. This approach provides patients with a better conceptual understanding of how this disease will affect their lives. More importantly, it stresses that “we” are in it together. We are about to embark on a journey from Point A (now) to Point B (the end of life). If we can arrive at Point B with the patient having good functional vision that will permit a high quality-of-life, then we have won the marathon. But, again, this is real life we are talking about. The path from A to B will inevitability present us with obstacles that will require properly identifying issues, evaluating solutions, and following through on decisions. In medicine, this breaks down to analyzing options when problems arise into choices that produce the best outcomes for our patients. The result is maximizing benefits while minimizing risks, or in other words, achieving the highest benefit-to-risk ratio.
Where does all this lead us? The best solution is to have a method that allows for the treatment of IOP that is safe and efficient, while also remaining versatile to the complex and unique situation of each individual glaucoma patient. The options are the following: eye drops, laser and surgery. When all factors are accounted for in this process, the answer with the best benefit-to-risk ratio is SLT. The reasoning is simple. It can be readily used in the entire spectrum of disease from high-risk ocular hypertension to severe stage pathology. The significant limitations that arise from the many causes of patient non-compliance is completely alleviated unlike that with which hampers drop use. The side-effect and risk profile is better than any surgical intervention that can be considered, from trabs and tubes all the way down to even MIGS. These characteristics not only differentiates SLT from its counterparts of drops and surgery, but also stresses the importance of having it around for use in any medical facility that treats glaucoma. In upcoming blog entries, we will dive even deeper in these specific issues. However, the fact remains the same – SLT should be in the armamentarium of every provider and be accessible to all patients. Interventions like trabeculoplasty allows us to successfully complete the journey with our patients to arrive at Point B.View all blog posts